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In some regions in the UK the RSA has become a prevalent choice in the managment of hallux valgus deformity. Its advocates often implement early weight-bearing recommending a sneaker or similar two weeks post-operatively.

A translation scarf appears to withstand weight bearing stresses well, when appropriate AO fixation is used, and cadaver studies have cofirmed this to be true. The eminent American Podiatrist Scott Weill even suggests wearing trainers one week after this surgery and this seems to work well. However, the intrinsic stability of this variation on the Scarf procedure has not been evaluated in the same way.

I have had the opportunity to evaluate a number of RSA patients 6 months post-operatively. In this review I have encountered undiagnosed basal 1st metatarsal fractures, loss of alignment and recurrence of the deformity at an unacceptable rate. Also, often the 1st metatarsal position appears good on XRF 2/52 PO only to see a significant gap at 6/12.

I am interested to hear from other surgeons with experience of this procedue and outcomes.

my opinion with regards to the scarf is that it can be inherintely unstable in certain patients,particularly patients over 55.when i was in residency we evaluated many scarfs that were at first described as malpositioned or with excessive motion leading to excessive bone callus.it was our belief then that what we were actually looking at were both fractures near the base as well as well as multiple stress fractures in the shaft of the metatarsal.
this is not to say that in younger patients with better bone stock they didn't work well.
however,they have a potential for lack of stability and avascular necrosis that far outweighs their benefis.i realize they are very popular in europe.but can anyone explain their advantage over let's say a reverdin (classic) with a closing base wedge,in order to correct a similar type of bunion.

I agree with you. I have had more that a few over-rotations (pushing the limits for correction), troughing, basal fractures and recurrence. I know I don’t have the experience of some of our UK colleagues but have my reservations when doing this procedure. Yes, you can walk them a 2 weeks but it can never be as stable as a purely translated Z without rotation.

I’m switching to basal chevrons/crescentics +/- modifications for my bigger angles. Ask me again in a year if I prefer these.

What are the factors that make this such a versatile and powerful procedure in the hands of one surgeon but capable of creating big headaches for others?

Is this a technical issue or is it more widespread and undetected? Are all patients followed up and x-rayed routinely at 6 months?

I suspect the angle of the longitudinal cut is a key component. The dorsal shelf has to be sufficiently thick and robust and I will direct this from dorsal to plantar in an oblique manner. Because I also insist on a gradual re-introduction to weight-bearing over a 4-6 weeks period I cannot isolate this as the only factor, but I have not seen a basal fracture complication when this is done.

Proponents of this procedure will say that avoidance of a BKC and the risk of cast disease can be eliminated with a Scarf cut and metatarsus primus elevatus is rarely encountered which cannot be said for the basal osteotomy. In good hands a rotation scarf and akin is completed in 35 minutes or less, reducing surgical time.

dieter,
thanks for the insight i will re-examine the rotational scarf.i currently utilize a three to two osteotomy approach for my younger active patients with high im and hav angles,oblique base wedge with either a reverdin or an akin.this is dependent on whether the im elevation is coupled with a high pasa or just a high hav.
however on my older patients i try to combine distal osteotomies,austin with akins,reverdin with akins or a fusion in severe deformities.i am concerned with using basilar osteotomies in the older population.

I understand the concern about healing capacity in the older patient but would say this: we must distinguish between chronological and physiological age. Unless there are specific factors to suggest otherwise, healing might not be impaired on the grounds of old age alone. I am not aware of any research to suggest otherwise.

In my professional practice I have encountered remarkably sprightly octagonarians and frighteningly unhealthy 40-year old patients. The choice of procedure, our wise old sages advice, embraces many variables, age is but one of those factors.

And there is this: we do not [?yet]have a "definitive" procedure that satisfies every patient's and/or clinician's needs and expectations.

Although I am critical of some aspects of the RSA this procedure appears to satisfy many, if not all, patients even when complications occur. And on top of all that, in doing so the RS osteotomy mocks the significance of PASA without any apparent ill effect.

At the same time I have witnessed excellent corrections addressing directly and predominantly the PASA with Reverdin Green Laird Todd procedure, in the mild to moderate IMA patient.

How is it that such a prevalent condition as HAV can respond favourably to a range of different procedures? Why is it that research has failed both to identify definitively the causative factors directing this pathlogy, and those procedures that appear adequately to correct the deformity?

And if this is truly the case, it makes sense to adopt a uniform approach. The RSA is versatile. Good fixation is possible. Early mobilization is achievable. Crutches and POP casts can be avoided. Deformity often is well corrected and patient satisfaction appears high.

Scarf osteotomy has gained popularity as one of the recommended procedures for moderate to severe hallux valgus. An Akin osteotomy may also allow additional correction but carries its own complications. The aim of this study was to assess the need for Akin osteotomy with a scarf procedure.

We reviewed our results of scarf osteotomy with and without Akin in 69 patients with 99 procedures. Sixteen patients (25 feet) had an Akin osteotomy with a scarf procedure. Radiological results were analysed by measuring the hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA) and the position of the tibial sesamoid. AOFAS scores were collected prospectively. Patient satisfaction was determined by whether or not they would have the operation again for a similar condition.

The mean age of the patients was 48.3 years (range 12–76) with a mean follow-up of 21 months. The mean improvement for the whole group in the IMA was from 15.8 to 7.9, HVA from 37.9 to 16.4 and DMAA from 19 to 9.9 was noted. The position of sesamoids improved from a mean of 5.8 to 2.3. The results were similar in both the groups and no significant difference was noted. AOFAS score improved from a mean of 53.6 preoperatively to 92.5 postoperatively. Three patients in the scarf group needed an Akin osteotomy as a revision procedure.

Scarf osteotomy alone may be an effective procedure for moderate to severe hallux valgus. An Akin osteotomy may be indicated if residual hallux valgus is noted during surgery.

Background
The scarf and the combined scarf-Akin procedures are reliable therapeutic tools and can obtain effective correction of symptomatic moderate to severe hallux valgus deformities.

Methods
The data from 30 patients (37 feet) with moderate to severe hallux valgus deformity who had scarf osteotomies have been retrospectively reviewed. 32 Akin and 77 Weil osteotomies were also carried out at the same stage. The average follow-up was 22 months. Standardized methods of radiographic and clinical data collection were obtained before and after surgery. Patient satisfaction was assessed at follow-up.

Results
Radiological assessment revealed a significant improvement (p < 0.001) of the hallux valgus angle (mean reduction 17.4°), the intermetatarsal angle (mean reduction 5.8°), the medial sesamoid position (14% of the feet were grade 1 or less preoperatively and this rate increased to 84% at follow-up) and the DMAA (mean reduction 9°). The complication rate was 19%. Clinical improvement was achieved with the AOFAS score increasing from 46 to 86 points (p < 0.001).

Conclusions
We conclude that the procedure has value in obtaining predictable correction of moderate to severe hallux valgus deformities.

The authors present the case of a 54-year-old female who developed a painful compression lesion localized to the medial aspect of the base of the distal phalanx of the great toe as a complication of hallux valgus surgery. Preoperative radiographic evaluation of the patient's foot revealed the first ray to be longer than the second, a 12 degrees first intermetatarsal angle, a 33 degrees hallux abductus angle, and an exostosis at the medial aspect of the base of the hallux that was not considered by the surgeon to be important. Correction of the hallux valgus deformity was performed with a combination of scarf and Akin osteotomies, and the intermetatarsal and hallux abductus angles reduced to 2 degrees and 8 degrees , respectively. By 2 months postoperative, the patient was complaining of pain at the medial aspect of the distal phalanx of the hallux associated with shoe pressure. The pain correlated both clinically and radiologically with the exostosis at the base of the distal phalanx, and had become symptomatic only after the hallux had been operatively realigned. At 6 months postoperative, percutaneous exostectomy was undertaken to remove the exostosis. Pain relief was complete, thereafter, and after 2 years of postoperative follow-up the patient remained pain free. The clinical importance of a medial exostosis localized to the base of the distal phalanx of the hallux must be taken into consideration whenever hallux valgus correction is undertaken, and this is particularly important whenever an Akin osteotomy is being considered

Dear colleagues:
In our experience we have found postoperative pain in the zone medial-plant of the articulation interfalángica, more usually than by on-correction in the processing of the hallux valgus (hallux varus iatrogenic), by not to have corrected wise the position of the valgus digital.
We should evaluate the angle ungueal in the pre-operating one, and to maintain it horizontal to the plan of the floor in the post-operating one.
If besides, limitation of the mobility is produced metatarsus-flanges, enlarges the conflict with the footwear in the union with its sole.
Kindly:
Jose Antonio Teatino
Professor of surgery
The Academy of Ambulatory Foot & Ankle Surgery

This study assessed the radiological measurements, American Orthopaedic Foot and Ankle Society (AOFAS) scores, and patient satisfaction associated with performance of the scarf osteotomy, combined with an Akin osteotomy, for the treatment of hallux valgus in patients at a general hospital. Thirty-five patients were assessed before surgery, and at 6 months following performance of the scarf first metatarsal osteotomy plus Akin osteotomy. The mean first intermetatarsal and hallux abductus angles reduced from 14.1 degrees +/- 3.5 degrees to 10.0 degrees +/- 3.2 degrees and 32.1 degrees +/- 9.9 degrees to 16.4 degrees +/- 7.9 degrees , respectively, and these differences were statistically significant (P < .001). The mean first to second metatarsal sagittal plane length ratio was unchanged by the osteotomy (P > .05). The mean global AOFAS Hallux Metatarsophalangeal-Interphalangeal score increased from 58.8 +/- 11.6 to 86.4 +/- 11.6, and this difference was statistically significant (P < .0001). Of the 35 patients (36 operated feet), 20 (57.1%) were extremely satisfied, 10 (28.6%) were satisfied, and 5 (14.3%) were unsatisfied with the results of the surgery. Based on these results, we concluded that the improved radiographic angles and AOFAS scores observed in this study were comparable to previously reported results, and our findings indicated that, in the setting of a general hospital, the scarf osteotomy combined with the Akin osteotomy is a safe, versatile and useful procedure for the treatment of hallux valgus

BACKGROUND: The presence of metatarsus adductus can complicate hallux valgus surgery. It reduces the gap between the first and second metatarsal and can restrict the transposition of the first metatarsal head. It also confounds the measurement of the first second intermetatarsal angle.

MATERIALS AND METHODS: Twenty-seven patients, (24 female, 38 feet), of average age 59 (SD 23) with symptomatic hallux valgus associated with metatarsus adductus underwent a rotation scarf with Akin osteotomy and were reviewed at an average of 59 (SD 23) months postop. Standard radiographic assessment of the hallux valgus was undertaken as well as measurement of the metatarsus adductus using the Kilmartin angle and the intermetatarsal angle of Engel.

CONCLUSION: The rotation scarf & Akin osteotomy was an effective procedure for correcting hallux valgus associated with metatarsus adductus. It allowed good realignment of the first MTP joint without the need for lesser metatarsal surgery to reduce the metatarsus adductus.

INTRODUCTION: The present study assessed 2-year clinical and radiological results of percutaneous correction of hallux valgus by Reverdin-Isham osteotomy and sought to clarify indications for the technique.

PATIENT AND METHODS: A continuous prospective single-center series of 104 cases of medium-to-moderate hallux valgus was managed by the same percutaneous technique, with a median 2 years' clinical and radiological follow-up (with no loss to follow-up). Uni- and multivariate analysis determined predictive factors for the mobility and degree of correction obtained.

RESULTS: American Orthopedic Foot and Ankle Society (AOFAS) functional score rose from a preoperative median of 49/100 to 87.5/100 postoperatively (p<0.05); 89% of patients were satisfied or very satisfied with their result at end of follow-up. Hallux valgus and distal metatarsal articular angle (DMAA) were significantly reduced (30 and 15 degrees to 15 and 7 degrees , respectively; p<0.05). Associated lateral ray surgery significantly increased the postoperative risk of MTP1 joint incongruence (p=0.009).

BACKGROUND: The traditional scarf osteotomy has been associated with complication rates between 1.1% and 45%. We have modified the traditional technique with a rotational osteotomy to reduce these complications.

PATIENTS AND METHODS: We retrospectively reviewed 140 patients: 38 men and 102 women with a mean age of 54 years (range, 35-66 years) who underwent surgery for HV and had a minimum followup of 24 months (mean, 41 months; range, 24-68 months). All patients had preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) forefoot and Short Form (SF)-36 V2 outcome scores recorded.

CONCLUSIONS: The modified rotational scarf osteotomy has a low complication rate (9%) and apparently reduces the risk of troughing. This procedure can reduce a high degree of IM angle deformity while restoring function to the forefoot.

BACKGROUND: The outcomes of hallux valgus surgery will be measured with reference to two discrete measures of health related quality of life (HRQOL). Clinical, radiographic outcomes and patient satisfaction will also be considered.

OBJECTIVES: To assess health related quality of life following rotation scarf and Akin's osteotomies.

CONCLUSIONS: Assessment of outcomes following surgical intervention is of critical importance to the foot surgeon. This study has demonstrated that the combined rotation scarf and Akin's procedure is a reliable procedure, capable of improving a patient's HRQOL.

BACKGROUND: The Akin osteotomy is a widely used procedure where various fixation methods are available, predominantly with the use of metallic component (wire, screw, staple etc.). The aim of this study is to demonstrate the results of our modified Akin procedures, where the fixation of the phalangeal osteotomy is achieved by absorbable suture, without metallic component.

MATERIALS AND METHODS: Between July 2004 and October 2008, authors performed their first 22 consecutive Akin procedures with the above technique. Mean age of patients was 49 [standard deviation (SD) 17, range 19-69] years. Mean follow-up time was 26 (SD 13, range 8-57) months.

RESULTS: Mean correction of the distal articular set angle (DASA) was 9.4 (SD 7.1, range 5-28) degrees. Mean shortening of the proximal phalanx was 1.8 (SD 1.0, range 0.3-4.1) mm. Among the 22 osteotomies, there was no evidence of non-union, delayed union, excessive bone callus, or loss of correction. 100% of the patients would undergo the procedure again, 91% (20/22) were completely satisfied; and 9% (2/22) were satisfied, including the one complication case.

CONCLUSION: The method presented in this study for fixation of the akin osteotomy showed results identical to the ones using conventional (metal) fixation techniques concerning radiological (correction of DASA, shortening of the proximal phalanx), and clinical (complication rate, subjective satisfaction rate) findings, without the risk of complication due to hardware irritation.

The Akin osteotomy is performed at the proximal phalanx for correction of an abducted great toe in a hallux abducto valgus deformity. Several internal fixation techniques have been widely advocated; however, their respective stabilities have not been compared. A biomechanical analysis was performed comparing 5 commonly used fixation techniques for the Akin osteotomy to determine the strongest method in simulated weightbearing in sawbone models. An Akin osteotomy was uniformly performed on 25 sawbones and fixated with 5 different internal fixation types, including a 2-hole locking plate and locking screws, a heat-sensitive memory staple (8 mm × 8 mm), a 28-gauge monofilament wire, 2.7-mm bicortical screws, and crossed 0.062-in. Kirschner wires. The results of simulated weightbearing load to failure rates with an Instron compression device demonstrated the following mean load to failures: crossed Kirschner wire, 57.05 N; 2-hole locking plate, 36.49 N; monofilament wire, 35.69 N; heat-sensitive memory staple, 34.32 N; and 2.7-mm bicortical screw, 13.66 N. Statistical analysis demonstrated the crossed Kirschner wire technique performed significantly better than the other fixation techniques (p < .007); the 4 other techniques were found not to be significantly different statistically (p = .041) from each another. Our study results suggest a crossing Kirschner wire construct significantly increases the stability of the Akin osteotomy in a sawbone model. This might be clinically extrapolated in an effort to improve patient outcomes because these osteotomies can undergo nonunion and malunion, resulting in postoperative pain and swelling.

Introduction Hallux valgus deformity is a common potentially painful condition. Over 150 orthopaedic procedures have been described to treat hallux valgus and the indication for surgery is pain intractable to nonoperative management.

Methods A retrospective analysis of the treatment of complex hallux valgus with bifocal metatarsal and Akin osteotomies of the first ray performed by the senior author (CC). 22 patients were treated over a three year period from 2008 to 2011, 24 trifocal osteotomies were undertaken. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were all measured from pre- and postoperative radiographs. The patients were also clinically reviewed.

Results The study group consisted of 21 women and 1 man with a mean age of 53 years. The average time to follow up was 19 months. Four cases had undergone previous surgery. Average HVA correction was 26.9 degrees (p < 0.0001), average IMA correction was 12.65 degrees (p < 0.0001). No patients had postoperative infection and all osteotomies went on to union. All patients reported resolution of pain. Two patients required removal of metalwork and the distal osteotomy angulated slightly in one patient not requiring reoperation.

Conclusion We demonstrate that bifocal metatarsal and akin osteotomies of the first ray are a safe and effective method of correcting complex hallux valgus.

years ago after having performed several SCARFS (rotational or not, almost all with an Akin osteotomy) I just could not see the benefits over a modified Austin, particularly with the increased amount of bone work and exposure needed.

It seemed to me, at the time and still today, that this procedure was devised mainly utilizing "osseous" templates rather than real life anatomy and surgical technique. At a time when incisions were getting smaller and post operative periods shrinking, it was interesting that this procedure became as popular as it did.

I'm sure many will disagree, particularly those that have gone on to make this their favorite bunion procedure.
Apparently surgery remains an art-form.

years ago after having performed several SCARFS (rotational or not, almost all with an Akin osteotomy) I just could not see the benefits over a modified Austin, particularly with the increased amount of bone work and exposure needed.

It seemed to me, at the time and still today, that this procedure was devised mainly utilizing "osseous" templates rather than real life anatomy and surgical technique. At a time when incisions were getting smaller and post operative periods shrinking, it was interesting that this procedure became as popular as it did.

I'm sure many will disagree, particularly those that have gone on to make this their favorite bunion procedure.
Apparently surgery remains an art-form.

Steve

Click to expand...

Steve,

The Scarf, along with it's many variations, can produce powerful correction even in the presence of advanced malalignment. In the right hands this approach will manage IMA 20+ and up to 30 degrees. The scarf can be used to shorten , and lengthen, dorsiflex and plantarflex, address PASA and IMA - in short, the scarf is the single most versatile procedure that will accommodate almost all variations of hallux valgus.

The Scarf, as practiced by many, is a near full length M1 osteotomy and can take correction of CORA (if you are an advocate of Paley's principles) much closer to the point of origin. When I look at the long term outcome of the Austin I see a marked deformity created in bone in an attempt to address a bony malalignment,

There is no true deformity in the metatarsal. The scarf does, I think, make a better job of it. At the same time it is a stable procedure capable of allowing a patient to return to sneakers s/p 2 weeks. The scarf provides the foot with such a degree of stability, it is almost never necessary now to consider a Lapidus to stabilize the medial column.

The incision is placed medial, usually, and along with plastic surgery technique the scar is not only hidden from the direct gaze of the observer looking down at the foot, but also usually fades nicely and becomes cosmetically very acceptable.

There is now, an embarrassment of wealth in the literature extolling the virtues of the scarf - which is not one procedure, but many. Incredibly versatile, robust and reliable.

The Scarf, along with it's many variations, can produce powerful correction even in the presence of advanced malalignment. In the right hands this approach will manage IMA 20+ and up to 30 degrees. The scarf can be used to shorten , and lengthen, dorsiflex and plantarflex, address PASA and IMA - in short, the scarf is the single most versatile procedure that will accommodate almost all variations of hallux valgus.

The Scarf, as practiced by many, is a near full length M1 osteotomy and can take correction of CORA (if you are an advocate of Paley's principles) much closer to the point of origin. When I look at the long term outcome of the Austin I see a marked deformity created in bone in an attempt to address a bony malalignment,

There is no true deformity in the metatarsal. The scarf does, I think, make a better job of it. At the same time it is a stable procedure capable of allowing a patient to return to sneakers s/p 2 weeks. The scarf provides the foot with such a degree of stability, it is almost never necessary now to consider a Lapidus to stabilize the medial column.

The incision is placed medial, usually, and along with plastic surgery technique the scar is not only hidden from the direct gaze of the observer looking down at the foot, but also usually fades nicely and becomes cosmetically very acceptable.

There is now, an embarrassment of wealth in the literature extolling the virtues of the scarf - which is not one procedure, but many. Incredibly versatile, robust and reliable.

As you note, horses for courses.

~Dieter

Click to expand...

Dieter:

You sound like a man of experience with this procedure. How many Scarf procedures have you done?

You sound like a man of experience with this procedure. How many Scarf procedures have you done?

Click to expand...

Hi Dr. Kirby,

To the order of 450-500, prior to my US relocation. Since then, I have been preaching the scarf bible to anyone who cares to listen. I have discovered the technique is not uniformly acknowledged on the east coast. And for all the same reasons that caused my hesitation / reluctance.

It took some 5 years of baby steps transition to both, fully accept the principle, and acquire the surgical finesse necessary to get the full potential out of it. Haven't looked back, since.

Be sure to apply to the Kaiser Sacramento program since I have been training their surgical residents on foot orthoses, biomechanics, sports medicine and the biomechanics of surgery now for the past 20+ years.:drinks

Be sure to apply to the Kaiser Sacramento program since I have been training their surgical residents on foot orthoses, biomechanics, sports medicine and the biomechanics of surgery now for the past 20+ years.:drinks

Don Green's San Diego program is one that feeds into Kaiser Sacramento. The other one comes from VA Albuquerque, I think. Both seem to be excellent programs. The 3rd year residents spend a half day a week learning biomechanics/sports medicine/surgical biomechanics in my private office. These residents get great all-round training and most of them end up being leaders in their communities when they finish up here, from what I have seen over the past 23 years of being part of the residency training program.

The Akin osteotomy is a frequently performed medial closing wedge osteotomy of the proximal phalanx of the hallux. It is usually used as a complimentary procedure in the correction of hallux valgus. Various implants and techniques have been described for fixation. Suture fixation has the advantage of a lower implant signature and a reduction in cost. However, the thin cortex of the phalanx can be prone to failure during suture application. We describe a new technique for suture fixation, which we have found to be reliable and to reduce the risk of phalangeal cortical failure.

Minimally invasive chevron and akin osteotomy are being used in a few centres in the UK. The purpose of our study was to analyse our early results and present our early experience of minimally invasive chevron and akin osteotomy (MICA) for the correction of mild to moderate hallux valgus.

This study assessed the radiological and clinical measurements, American Orthopaedic Foot and Ankle Society (AOFAS) scores, pain scores and patient satisfaction associated with performance of the MICA, for the treatment of hallux valgus.

Between September 2010 and April 2012, 96 consecutive patients (122 feet) who underwent MICA were assessed. The overall satisfaction rate was over 90%. The mean total AOFAS score was 89.7 points. VAS for pain reduced from a mean of 7.4 to less than 1 point. On weight bearing anterior-posterior foot radiographs there was a significant improvement in the mean IMA and HVA.

Complications included 2 episodes of superficial infection (1.6%), 1 fracture (0.8%), 4 incidence of nerve injury (3.3%) (Numbness) and 9 patients requiring removal of screw (7.4%). However, these screw removals occurred early on in the study and diminished after a slight modification in surgical technique.

Based on our findings we concluded that MICA is an effective procedure with good patient satisfaction in the treatment of mild to moderate hallux valgus.

Background
Hallux valgus deformity is not a single disorder as the name might imply, but a complex multifactorial deformity of the first ray that is often accompanied by deformity and symptoms of pain even in the lesser toes. Research into foot pain has been limited by the lack of a clear understanding as a whole as to what constitutes foot problems. The aim of this study was to measure the effects of the combined Scarf and Akin’s osteotomy with or without 2/3 toe correction for Hallux valgus deformity at 6 months period. Outcome measures used were the pain scale (VAS) and the Manchester-Oxford Foot Questionnaire (MOXFQ).
Methods
The study was a prospective design and included 30 patients aged 18 to 65+ years with painful bunions plus or minus lesser toe involvement with foot deformity in the study who went on to be treated by the above mentioned surgical procedure with normal heel postoperative weightbearing in a stiff soled surgical shoe during a 6 months period. Mean age of patients at the time of surgery was 59 years, 25 patients were female and 4 were male. History and physical pre-operative assessments (clinical and radiographic) including outcome measures (VAS & MOXFQ) results were performed both at baseline and at 6 months. Post-operative management of the patients was as per normal guidelines set by the department of Podiatric Surgery following a reconstructive bunion surgery.
Results
The patient related outcome measures, VAS and the MOXFQ questionnaire for the cohort clearly showed statistical significances following foot surgery. The VAS pain scale domain, the median based on the post-surgical scores, was reduced to 0 (IQR 0) with a score change of -6 (IQR 3) (P<0.001). The MOXFQ pain domain, the median based on the post-surgical scores, was reduced to 5 (IQR 0) with a score change of -55 (IQR 27) (P<0.001). The MOXFQ walking and standing domain, the median based on the post-surgical scores was reduced to 0 (IQR 15) with a score change of -50 (IQR 28) (P<0.001). The MOXFQ social interaction domain, the median based on the post-surgical scores, was reduced to 0 (IQR 7) with a score change of -50 (IQR 25) (P<0.001). No post-operative complications were observed, only one patient was lost to post op follow up and her data was discarded.
Conclusion
A combined Scarf Akin osteotomy with or without 2/3 toe is an effective procedure for the correction of symptomatic Hallux valgus foot deformity at 6 months. It permits early weight bearing of the treated extremity and it requires exact pre-operative planning and strict adherence to the operative technique if pain is to be effectively eliminated and the HRQOL restored with above satisfactory results.

Hi Dieter:
Looking at this OLD thread from last year......Apparently I never read your reply post. Sorry.

Wondering if you are still enamored with the SCARF?
Also looking at your post from last October, you mentions lengthening the metatarsal. Have you lengthened many and how is the ROM on follow up?
Can you also comment on what "marked deformity" you were referring to on the Austin type osteotomies?

Hi Dieter:
Looking at this OLD thread from last year......Apparently I never read your reply post. Sorry.

Wondering if you are still enamored with the SCARF?
Also looking at your post from last October, you mentions lengthening the metatarsal. Have you lengthened many and how is the ROM on follow up?
Can you also comment on what "marked deformity" you were referring to on the Austin type osteotomies?

Click to expand...

HI Steve,

Yes indeed I am. But I refer in particular to the Barouk Scarf-Akin modification, and I dare say, Fellner modification which evolves naturally with experience. I have never lengthened the 1st metatarsal when addressing the virgin bunion. And for the reason you allude to: 1st MTPJ jamming is a likely sequela. A key component of lasting correction is decompression, offset by 1st met plantar flexion. In my experience, the correct saggital plane position will determine the risk of lesser metatarsalgia, not the absolute length of the 1st metatarsal (within reason).

The being said, in my current capacity as PGY-1 resident, there is no opportunity to indulge my passion. On one occasion, I was able to convert skeptics, when I received an impromptu invitation to act as surgical instructor during an externship at one of the NYC hospitals. I have an open minded Residency Director who may, in all likelihood indulge my convictions, in Year 2.

As for the Austin - the capital fragment is translated laterally creating a deformity in the bone. This has become a point of interest. I am exploring HAV correction without cutting bone as the primary means to address HAV. A work in progress.

I was under the impression that you were practicing. Good to hear that you have a passion for foot surgery.

As for someone who has the same passion for the Austin (I might add with the Arbes modification - TIC) as you do for the SCARF,
I would argue that ANY osteotomy causes a "deformity" and in fact, given enough time and by the graces of Wolff's Law, these diminish. Merely based on the fact that an AP post SCARF "looks" more anatomic because of the overall shape of the metatarsal doesn't mean you have created less "deformity. In addition, I've come to appreciate the over-emphasis we sometimes place on the radiograph and how it related clinically.

Interesting how most surgeons gravitate to a particular bunion procedure or other based upon their expertise (read good results) regardless of possible poor outcomes obtained by others. I would venture to guess that after 500 or 1000 bunionectomies we all develop our myraid of modifications, often perhaps not even appreciating their arrival.

As for non osseous correction of bunions ........ Good luck, just don't re invent the McBride! LOL

I was under the impression that you were practicing. Good to hear that you have a passion for foot surgery.

As for someone who has the same passion for the Austin (I might add with the Arbes modification - TIC) as you do for the SCARF,
I would argue that ANY osteotomy causes a "deformity" and in fact, given enough time and by the graces of Wolff's Law, these diminish. Merely based on the fact that an AP post SCARF "looks" more anatomic because of the overall shape of the metatarsal doesn't mean you have created less "deformity. In addition, I've come to appreciate the over-emphasis we sometimes place on the radiograph and how it related clinically.

Interesting how most surgeons gravitate to a particular bunion procedure or other based upon their expertise (read good results) regardless of possible poor outcomes obtained by others. I would venture to guess that after 500 or 1000 bunionectomies we all develop our myraid of modifications, often perhaps not even appreciating their arrival.

As for non osseous correction of bunions ........ Good luck, just don't re invent the McBride! LOL

Steve

Click to expand...

Steve,

Your impression is correct. I served for 20 years prior to my US relocation. I can construct a compelling argument why the Austin doesn't make the cut. But this will have to wait, another day.

Background
Hallux valgus deformity is not a single disorder as the name might imply, but a complex multifactorial deformity of the first ray that is often accompanied by deformity and symptoms of pain even in the lesser toes. Research into foot pain has been limited by the lack of a clear understanding as a whole as to what constitutes foot problems. The aim of this study was to measure the effects of the combined Scarf and Akin’s osteotomy with or without 2/3 toe correction for Hallux valgus deformity at 6 months period. Outcome measures used were the pain scale (VAS) and the Manchester-Oxford Foot Questionnaire (MOXFQ).

Methods
The study was a prospective design and included 30 patients aged 18 to 65+ years with painful bunions plus or minus lesser toe involvement with foot deformity in the study who went on to be treated by the above mentioned surgical procedure with normal heel postoperative weightbearing in a stiff soled surgical shoe during a 6 months period. Mean age of patients at the time of surgery was 59 years, 25 patients were female and 4 were male. History and physical pre-operative assessments (clinical and radiographic) including outcome measures (VAS & MOXFQ) results were performed both at baseline and at 6 months. Post-operative management of the patients was as per normal guidelines set by the department of Podiatric Surgery following a reconstructive bunion surgery.

Results
The patient related outcome measures, VAS and the MOXFQ questionnaire for the cohort clearly showed statistical significances following foot surgery. The VAS pain scale domain, the median based on the post-surgical scores, was reduced to 0 (IQR 0) with a score change of -6 (IQR 3) (P<0.001). The MOXFQ pain domain, the median based on the post-surgical scores, was reduced to 5 (IQR 0) with a score change of -55 (IQR 27) (P<0.001). The MOXFQ walking and standing domain, the median based on the post-surgical scores was reduced to 0 (IQR 15) with a score change of -50 (IQR 28) (P<0.001). The MOXFQ social interaction domain, the median based on the post-surgical scores, was reduced to 0 (IQR 7) with a score change of -50 (IQR 25) (P<0.001). No post-operative complications were observed, only one patient was lost to post op follow up and her data was discarded.

Conclusion
A combined Scarf Akin osteotomy with or without 2/3 toe is an effective procedure for the correction of symptomatic Hallux valgus foot deformity at 6 months. It permits early weight bearing of the treated extremity and it requires exact pre-operative planning and strict adherence to the operative technique if pain is to be effectively eliminated and the HRQOL restored with above satisfactory results.